As hypothesized, participants in HOPES showed significantly greater improvement across many of the psychosocial outcomes. Specifically, HOPES participants improved more in social skills, community functioning, negative symptoms, self-efficacy, and leisure and recreation. The improved social skill of the HOPES participants and the greater reduction in negative symptoms are consistent with a smaller trial of social skills training with older persons with psychosis (Patterson et al., 2003
). Similarly, improved leisure functioning is consistent with a prior study evaluating combined social skills training and cognitive restructuring in middle aged-older adults (Granholm et al., 2005
). This study extends prior research by demonstrating these effects in a mixed sample of older adults with schizophrenia-spectrum and major mood disorders, and by showing effects on a broad measure of community functioning. These findings confirm that psychosocial rehabilitation can benefit older adults with SMI who have long-standing impairments in community functioning.
Participants in HOPES did not differ from those in TAU on any of the independent living subscales of the ILSS other than the leisure and recreation subscale. The lack of differences in these areas may reflect the limited attention to these skill areas in the HOPES program. While one six-week module focused on leisure and recreation skills, only one or two sessions were spent on transportation, money management, and food preparation, and none addressed work, personal hygiene, or home maintenance. Furthermore, while two HOPES modules addressed health self-management, their focus was on healthy living (e.g., sleep habits, diet and exercise) and effective skills for interacting with health care providers. In contrast, the ILSS health maintenance subscale reflects such areas as self-reported medication adherence, safe cigarette smoking, and knowledge about insurance for medical benefits.
Participants in HOPES demonstrated significantly greater improvements in negative symptoms. These findings are consistent with those reported by Patterson and colleagues (2003)
in their skills training program for older persons with schizophrenia, although similar effects were not found in Granholm et al’s (2005)
combined skills training and cognitive behavioral intervention. Negative symptoms are strongly related to social skill and psychosocial functioning (Mueser, Douglas, Bellack, & Morrison, 1991
; Pogue-Geile & Harrow, 1985
), including in older people with schizophrenia (McGurk et al., 2000
). Skills training has been shown to improve negative symptoms in other studies of schizophrenia, with a recent meta-analysis reporting an effect size of .40 in controlled studies (Kurtz & Mueser, 2008
). The effect size of .53 at two years in this study was slightly higher, although the sample was diagnostically heterogeneous. The findings suggest that skills training may help address the challenging problem of negative symptoms (Kirkpatrick, Fenton, Carpenter, & Marder, 2006
) both in older persons with schizophrenia, as well as those with severe mood disorders.
HOPES had a significant impact on self-efficacy during the first year, although by the second year participants who had received TAU had improved and the groups were no longer different. This improvement in the TAU group is puzzling, considering that no specific social rehabilitation services were provided to target this domain. Self-efficacy has been hypothesized to contribute to psychosocial functioning in schizophrenia (Liberman et al., 1986
). However, one study found that self-efficacy did not mediate the relationship between negative symptoms and functioning, but rather negative symptoms mediated the relationship between self-efficacy and functioning (Pratt et al., 2005
). The present findings are consistent with that mediation analysis because both participants in HOPES and TAU improved in self-efficacy, but only those in HOPES improved in both negative symptoms and psychosocial functioning.
Our findings provide some support for our hypothesis that HOPES would have stronger effects on performance-based measures of skills training than community functioning. Effect sizes for the UPSA were stronger at both one (.51) and two (.45) years than the corresponding effect sizes for overall functioning measured on the Multnomah (.44, 37), the SBS (−.20, −.29), or the ILSS (.25, .32). Interestingly, this same hypothesis was not supported in the recent meta-analysis of social skills training for schizophrenia, which found the same magnitude of effect sizes (.52) for both measures of skill performance and community functioning (Kurtz & Mueser, 2008
). Perhaps factors other than skills play a role in improving community functioning, such as instilling hope and providing encouragement to pursue social and related goals.
The heterogeneous diagnostic composition of our study sample is representative of persons with SMI commonly served by public sector mental health service providers. Thus, results from this study are likely to generalize to populations, services, and usual care providers that commonly provide services to a broad range of persons with SMI, rather than diagnosis-specific services. Although there was one significant diagnosis by treatment group interaction, the lack of other such interactions, combined with moderately strong statistical power, suggests that HOPES was equally beneficial to participants with both mood and schizophrenia-spectrum disorders, and thus may be applicable to the broad population of older persons with SMI.
The impact of HOPES on functioning was significant, with most effect sizes in the moderate range. This is comparable to the impact of social skills training on functioning for younger people with schizophrenia (Kurtz & Mueser, 2008
), and other psychosocial treatments for schizophrenia mainly evaluated with younger individuals, including cognitive remediation (McGurk, Twamley, Sitzer, McHugo, & Mueser, 2007
) and cognitive-behavioral therapy for psychosis (Wykes, Steel, Everitt, & Tarrier, 2008
). However, the clinical significance of the observed improvements in functioning is difficult to determine. All of the participants had SMI, and therefore remission of mental illness or elimination of functional impairment was not an anticipated effect of treatment. A 2-point change on the Multnomah is relatively small considering the range of possible scores between 17 and 85, and could correspond to an improvement on just one of the 17 items. Nevertheless, significant changes were observed in some clients who participated in HOPES. For example, one man with schizophrenia who lived in a group home and was socially isolated before HOPES spent began to socialize with others and made several friends with whom he played chess regularly. One woman in HOPES with bipolar disorder who lived with her daughter and was extremely dependent upon her for basic social and living needs moved out into her own apartment, learned how to budget and use public transportation, and became actively involved in her local senior citizens center. These gains were unique and important to each individual, yet are not easily captured with the currently available measures of psychosocial functioning.
In order to explore whether certain factors predicted differential response to HOPES we compared effect sizes at two years for subgroups based on gender, diagnosis, age, cognitive functioning, psychosocial functioning, and social skill. Only gender was consistently related to effect size across all seven outcome measures, with a median effect size for males of .69 compared to only .19 for women. Furthermore, statistical analyses evaluating gender by treatment group interactions were significant for the ILSS and SBS. Two other non-controlled studies of social skills training in younger persons with schizophrenia have reported that men fared better than women (Mueser, Levine et al., 1990
; Schaub et al., 1998
It is unclear why men appeared to benefit more from HOPES than women. Men with SMI tend to have more severe psychosocial impairment than women (Angermeyer, Kuhn, & Goldstein, 1990
; Mueser, Bellack, Morrison, & Wade, 1990
; Usall, Haro, Ochoa, Marquez, & Araya, 2002
), and in this study men had lower functioning at baseline on some but not all measures. The better outcomes for HOPES males does not appear to be due their worse functioning and greater potential for improvement because subgroup analyses based on overall level of psychosocial functioning or social skill failed to find consistent differences in response to HOPES. Social skills training approaches for SMI may have been developed with greater attention to the needs of men than women because of their more pronounced impairments. For example, in the Kurtz and Mueser (2008)
meta-analysis of social skills training, 71% of study participants were male, with an average age of 37.7 years. Another possibility is that gender differences in the social functioning of persons with SMI may have led to the development of measures that are more attuned to the characteristic impairments of men, and hence are more sensitive to change. Further research is needed to explore these and other possible explanations for the gender difference in response to the HOPES program.
HOPES was relatively intensive to implement, and the overall duration of the program was relatively long, raising the question of whether it could be abbreviated and achieve the same benefits. As previously described, HOPES included seven discrete modules, which were designed as stand-alone modules, obviating the need to provide an entire year of skills training. Future research is needed to evaluate more efficient methods for delivering psychiatric rehabilitation, as well as tailoring curriculum and teaching methods so they can be delivered to individuals who may have difficulty accessing groups.
Several limitations of this study should be noted. First, the control group received only usual services, with no attempt to control for the non-specific effects of clinician contact. The decision to compare HOPES to TAU, rather than an “attention control” treatment, was based on the fact that there is no compelling evidence supporting any intervention for improving the community functioning of older people with SMI, suggesting that what the field needs most is a standardized program capable of making those changes. Subsequent research could dismantle the intervention by evaluating the additive benefit of skills training to non-specific clinical contact. Another limitation was the relative lack of ethnic and racial diversity in the sample. Additional work is needed to evaluate HOPES in more diverse populations, and to explore the need for cultural adaptations, such as those developed by Patterson et al. (2005)
for older Latino individuals with SMI. Finally, we have limited ability to speculate about the generalizability of the findings to the larger population of older people with SMI. Of the 725 individuals who were invited to join the study, approximately two-thirds declined. We were not able to collect any information about those individuals who declined other than their reason for declining, therefore, it is unclear whether those who chose to participate differed in any substantive, important ways from those who refused. The most frequently stated reasons for declining, among those who provided a reason (N
= 309), were: 1) commitments that competed with the group day and time such as work or other mental health services (37%), unwillingness to join a group or receive additional mental health services (27%), lack of feasibility due to mobility, legal, medical, and other issues (17%), and lack of engagement in any services (14%).
These limitations notwithstanding, several strengths of the study are notable. Multiple methods were used to evaluate social skill and community functioning, including performance-based, self-report, and informant ratings, overcoming the limitations inherent in relying on a single source of data. The duration of HOPES allowed for an assessment of the sustainability of functional improvement over time. Prior skills training studies with older participants have been conducted for shorter periods and with briefer follow-up periods (Granholm et al., 2005
; Patterson et al., 2003
), which may partly account for their mixed results. Also, HOPES was implemented across three different treatment centers, with no evidence of differential effectiveness between sites, with a diagnostically heterogeneous sample, and with a large enough sample size to have sufficient statistical power to detect effects on community functioning. These characteristics support the potential effectiveness of HOPES in different settings serving the broad population of older adults with SMI. There was an excellent rate of exposure to HOPES (80%) and retention in research at the follow-up assessments. This is especially remarkable considering the age of the participants (mean age = 60), supporting the feasibility and robustness of the program for older adults. Finally, whereas other psychosocial rehabilitation programs developed for older people focus on skills training alone, the HOPES program also incorporated medical case management, responding to the critical need to address physical health of older adults with SMI.
In summary, participation in the HOPES program was associated with significantly greater improvements in social skill, community functioning, and negative symptoms compared to TAU in older persons with SMI. Social and community functioning are critical to the well-being of older people with SMI. The HOPES program has the potential to improve functioning and sustain community living in aging adults with SMI and to reduce critical risk factors associated with high rates of institutionalization and disability. The time duration of this report (two years) was too brief to detect any possible advantages of HOPES in extending community tenure, but we plan to examine this in a subsequent paper with a longer follow-up. With the rapidly growing population of older people with SMI, there is a pressing need for development and implementation of effective and age-appropriate psychosocial rehabilitation interventions aimed at improving community functioning and tenure.